Dr Melmed, from Cedars-Sinai Medical Center in Los Angeles, reviewed how to implement successful, practical quality improvements to the practice of gastroenterology to optimize outcomes among patients with inflammatory bowel disease.

Gil Y Melmed, MD, is director of Inflammatory Bowel Disease Clinical Research and codirector of the Clinical Inflammatory Bowel Disease program at Cedars-Sinai Medical Center in Los Angeles, California.

TRANSCRIPT:

Dr. Gil Y. Melmed:

Hi, I'm Dr. Gil Melmed from Cedar Sinai in Los Angeles. And I had the pleasure of speaking at DDW on the topic of translating evidence into quality for patients with inflammatory bowel disease. And what the focus of my talk was, was really to try to understand what can we learn from the literature in IBD and in the literature for quality improvement that can be practical, relevant, and applicable to one's day-to-day practice to help them take better care of their patients. So we explored how to implement successful quality improvement in practice with patients and stakeholders. We talked about applying concepts in practices and in institutions, and also touched on how to create a QI project within your own practice and to evaluate the impact of that QI project on patient care. And this is not new. In IBD actually, there have been programs for quality improvement for several years, but actually perhaps the greatest example of the success of quality improvement in healthcare comes from another condition.

We've learned from cystic fibrosis back in the sixties and seventies and eighties, that cystic fibrosis was a mortal lethal condition, but all of a sudden the survival rates of people with cystic fibrosis significantly improved between the fifties and the sixties all the way through 2010 before a drug was ever approved for cystic fibrosis. And what has been attributed to that longevity and improved mortality in patients with cystic fibrosis was the development of a quality improvement collaborative, which involved centers from around the country getting together, sharing best practices and applying quality improvement methods to help them take better care of their patients through rigorous quality improvement programs. And the idea behind a quality improvement program is that it's not a clinical trial. You're not necessarily following a protocol with strict criteria, strict outcomes, and a clear beginning and an end, and then you're done. Quality improvement's very different. Quality improvement involves small iterative changes.

It involves testing something before implementing it on a broad scale. It involves small scale before rolling out to a larger scale. And what's absolutely critical in quality improvement is the concept of measurement, of metrics. You can try to improve something, but if you're not measuring the outcome that you're trying to improve, you won't know that you made an improvement. So picking metrics that one can assess easily and follow over time is absolutely critical to the success of any QI project. One significant buzzword within quality improvement literature is the concept of variation. When variation is seen, either in how people do things or in the outcomes of patients exposed to particular intervention, when there's variation, we have to wonder why? Why is there variation? And oftentimes it points to people doing things differently, doing things more so or less so or differently than others. And understanding variation therefore can help to streamline so that consistent results can be achieved when the same process is applied in a consistent manner.

There are actually several methods of quality improvement. One that's been commonly applied in medicine is the model for improvement. The model for improvement involves identifying aims, what are you trying to achieve, measures or metrics as we've discussed. And then finally figuring out what is the change one is going to make in order to try to achieve that improvement. And by asking those three questions on a small scale, and then in a large scale, one can then begin to understand how to move forward in a quality improvement manner. So when we think about quality improvement measures, we think about different kinds of measures. We have measures of structure of the healthcare system in which one operates. A structure measure might be how many nurses per patient might there be in a hospital, or how many nurses do you have in your practice?

How many rooms do you have in your practice? Do you have access to specialized colorectal surgeon? Those would be structure measures. A process measure would be processes of care, things that you do in your office, things that you do in your control about your decisions of how you take care of patients. And then there are outcome measures with respect to patients. Ultimately, we can determine good quality of care, not so much based on the structure process, but really based on the outcomes, because that's ultimately what we're trying to achieve is better outcomes for our patients. But it's often very hard to measure outcomes. It's hard to document them. It's hard to understand what they are. In inflammatory bowel disease, perhaps outcomes might include surgical rates, hospitalization rates, and those may be hard to measure in a clinical practice. But what may be much easier to measure would be processes of care that are in your control.

Through the Crohn's and Colitis Foundation, we've published what suggested process and outcome measures may include for inflammatory bowel disease, and they include outcomes such as steroid free clinical remission, the number of days lost from school or work, emergency room visits, hospitalizations, but also some very patient-oriented outcomes such as the presence or absence of incontinence, quality of life, health related quality of life, nighttime bowel movements or leakage at night. And so these outcomes can be quite variable and really your choice of what you want to improve can help you find a QI project that is best suited for your particular clinical practice setting in your particular patient population. But there's other measures or metrics that you may want to think about to improve for other reasons where they may not necessarily ultimately improve patient outcomes, but they may improve patient satisfaction. They may improve healthcare costs.

So for example, process measures that can impact patient care might include in a practice the time to return a phone call, documenting small iterative practice changes to help improve the time to return a phone call, particularly for a patient calling with an urgent need could be a huge satisfier for patients and perhaps ultimately may even influence patient outcomes, perhaps with respect to their access and need for unplanned visits to the emergency room. Understanding what proportion of your patients are already scheduled for a follow-up visit or may not be scheduled for a follow-up visit. What is the time from a phone call that's urgent to getting a patient into the office to be seen perhaps before they end up in the emergency room? And several other process measures that again, are more easily measured than outcomes and in your control as the clinician may provide opportunities to introduce quality improvement into your practice.

There's lots of evidence for successful QI projects that have been published, although some QI projects or many QI projects may not be published because they're small scale. And again, they aren't necessarily designed like clinical trials with P values and endpoints that can be readily published. But there are a number of opportunities in the literature that have been seen. For example, improving vaccination rates, improving c diff screening, improving the use of DVT prophylaxis in patients who are hospitalized. And there's quite a robust body of evidence that has been growing with a systematic review that was recently published by David Fuman in 2022, summarizing all of the published literature on successfully published QI projects.

So for a practice that's interested in applying some QI methodology, starting a QI project in your practice, there's several different ways one can think about participating in quality improvement. One might be to join a quality improvement network such as IBD Chorus. IBD Chorus is a nationwide QI program funded by the Crohn's and Colitis Foundation that now includes close to 50 sites around the country that all engage in plan due study act cycles of quality improvement together measuring patient outcomes and provider processes together, learning from each other, receiving report cards of how they're doing on particular metrics. And through this program, the IBD Chorus program, reduction in emergency room utilization, hospitalizations, corticosteroid use, urgent care need have all been demonstrated as hard outcomes benefiting patients that can actually be demonstrated and achieved using QI methodology. But it doesn't necessarily have to be through a large QI program. One can start a small scale QI project in their own office. You can start next week, set a weekly time for your team that gets together on a regular basis, weekly basis, ideally to discuss QI, to discuss what can we work on together?

What are the changes that we need to make that could result in an improvement? How are we going to measure that? And what did we learn from the last time we made such a change? And how can we tweak that change to actually improve that process going forward? Write those down. Write down your aims, your measures, and your changes. Know your denominator. How can you understand the impact you're having on your IBD population if you don't know how many patients with IBD you take care of. So understanding the denominator of the patients that you're trying to help, in this case we're talking about inflammatory bowel disease will be critically important in order to be able to put numbers and metrics to that quality improvement process that you're going to initiate.

Start small. Start with a small test of change. If you want to, for example, reduce the number of phone calls that are left on the answering machine at the end of the day, perhaps your test of change will be that one of the nurses will stop their day half an hour early and clear all the messages from the machine. Maybe a half hour is too long, maybe it's too short. Maybe it needs to be 15 minutes, maybe it needs to be an hour. That's something that one would learn through assessment of the following week, what happened when we made that test of change, and then understand how that could be changed for the better.

So ultimately, in summary, quality improvement is quite variable. There's a lot of different ways to begin the quality improvement process to introduce quality improvement into one's practice. There is a good body of literature that supports the utilization of quality improvement, both in medicine in general and in IBD now specifically, much of which can be learned and applied to one's individual practice, but also could be achieved through joining a large scale quality improvement program. Low cost process changes can actually make a big difference to patient outcomes. And so utilizing quality improvement methods and techniques can help you achieve better outcomes for your patients. Thank you very much for your attention.